Care Review Bureau - News

Care trust repays £30,000 after wrongly charging for care

April 29th, 2011 | The Telegraph

Simon Binder’s father ‘would have starved without care’ but he was told didn’t qualify for funding.

Telegraph reader has been awarded almost £30,000 after his local primary care trust wrongly assessed his father’s care needs. The case demonstrates the “postcode lottery” many people face when trying to find a fund for long-term care for elderly relatives.

Simon Binder’s father Reuben suffered a stroke in February 2009, leaving him unable to move or communicate, aside from restricted movement in one hand and blinking one eye.

But despite these extensive disabilities Brent Primary Care Trust (PCT) concluded in May of that year that he did not have severe enough health needs to qualify for “continuing care” – which would have meant the cost of his care would be paid for by the health authorities. Instead, Mr Binder was charged for the 24-hour nursing care his father needed.

In September 2009 Mr Binder contacted specialist firm Paladin Advocates, which arranged for Reuben to be assessed by an alternative PCT as his nursing home fell within Barnet’s PCT.

A month later he was told he qualified for continuing care and was awarded funding, despite there having been no deterioration in his condition since his first assessment. Barnet PCT said “it was never in doubt he would qualify&dquo;. Reuben died just a month later on October 23 2009.

Paladin then advised Mr Binder to appeal to Brent PCT to get his father’s care costs reimbursed. After three appeals, in which Brent upheld their assessment that Reuben did not have a “primary health need”, the case was independently reviewed by the Strategic Health Authority, which ruled that the decisions made by Brent PCT were unsound and recommended that costs be refunded. They came to a total of £27,000.

The real question is why two PCTs came to such difference conclusions when both follow the same national care guidelines.

Before October 2007, each PCT set its own guidelines for determining who qualified for this “free” continuing care. But this hotch-potch arrangement was swept away by the Health Service Ombudsman, as evidence suggested it was creating huge regional differences when it came to care of the elderly.

From this date national guidelines have been issued to care trusts, in order to put an end to the geographical disparity – but, as cases such as this illustrate, they have not been as successful as many hoped.

“I have been inundated with as many enquiries as ever,” said Anne Reed, a former nurse and trained lawyer, who founded Paladin after a battle with a Cornwall PCT following her late mother’s illness.

“Since I started the business 18 months ago I would say I have an average of two enquiries a day. There has been no improvement in the long-term care postcode lottery – it is a continuing nightmare.”

Anyone needing care is entitled to a health assessment. This should determine whether they qualify for continuing care, or if not, what level of nursing care contribution they should receive instead.

The first part of the assessment is a checklist to identify whether you are a candidate for continuing care. Part two is broken down into 11 “care domains”: behaviour, communication, emotional needs, understanding, mobility, nutrition, continence, wounds and ulcers, breathing, medication and consciousness.

For each of these domains, the individual is graded either priority, severe, high, moderate or low.

Depending on how you “score” on each, the PCT assessor will rule whether you have a “primary health need” and qualify for free long-term care. The guidelines state that one “priority” or two “severe” classifications is enough to qualify for continuing care.

If you do not meet the criteria you may still be eligible for nursing care contribution. This would only cover nursing care costs however, not personal care fees. These should be paid for if you qualify for continuing care. And, as Mr Binden found, these costs can run into tens of thousands of pounds a year.

Even though the criteria for free continuing care are the same across the country, critics say they can be interpreted in different ways, partly because of the “vague” way in which they are framed.

Ms Reed said: “A national framework exists, but PCTs don’t know how to apply the criteria. It seems the attitude is defensive and aggressive and it’s the same all over the country.

“I deal with PCTs from Newcastle, Cornwall, Suffolk and Wirral – no one area seems any better than anywhere else. The NHS Act of 1947 stipulated that it would provide care from the cradle to the grave, and that just doesn’t seem to be the case.”

Mr Binder said that if one thing could have been done differently in the case of his father he would wish for common sense to play a part in assessment.

“If my father had been left to fend for himself for 24 hours he would have starved, and yet we were told he didn’t qualify for care. We sat in a room with people telling us things that just didn’t make logical sense. These rules were drafted by good people, and yet something along the way has been distorted,” he said.


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